Lord Broers: My Lords, this is, as all noble Lords will be aware, a highly topical debate. When the Science and Technology Committee decided last summer to undertake a short inquiry into pandemic influenza, we decided that we should if at all possible report before the end of the year, because we were well aware that if we delayed our inquiry it could very easily be overtaken by events in the winter. We also decided to seek a debate as a matter of urgency, without waiting for the Government to produce their response, and that is why we are discussing the report today. I am grateful to the staff of the Government Chief Whip's Office for their help in arranging such a timely debate. Events in the past month, in Turkey and elsewhere, have fully vindicated our urgency.
	Before moving onto the substance of my remarks, I would like to offer a few words of thanks—first, to our specialist adviser, Professor Julius Weinberg, who was also the adviser for our earlier report on fighting infection, and whose advice was invaluable in interpreting the evidence that we received and setting it in context; and to our Clerk, Christopher Johnson, the committee specialist Jonathan Radcliffe and their support staff, whose professionalism in organising our sessions and in drafting the report was outstanding.
	I shall now turn to the report itself and highlight some of our main conclusions. At the end of my speech, I shall touch on recent developments in Turkey and beyond.
	We know that there have been regular influenza pandemics—roughly three a century—in the past, and it seems inevitable that there will be further pandemics in future. The virus has not gone away; it is endemic in wild birds and the process of mutation means that new strains will emerge from time to time that will attack either domesticated poultry, or, occasionally, human beings. But we cannot say when the next pandemic will be; we cannot even say when it is likely to happen.
	What we do know is that since 2003 a virulent strain of avian flu in south-east Asia, H5N1, has passed from birds to more than 100 people, killing about half of those infected—79, according to the latest World Health Organisation figures. Let us be clear that H5N1 is bird flu, not pandemic flu. It cannot pass efficiently from person to person and may never acquire the ability to do so, in which case it will not trigger a human pandemic. But it has shown the ability to pass from birds to human beings, and to kill those it has infected. This alone suggests that the world is closer now to a pandemic than at any time since the 1960s.
	It is not too late for international action to reduce the likelihood that H5N1 turns from a disease of birds into a human pandemic. That is a central theme of our report. One of our chapters is entitled, "Prevention is better than cure". We should be strong partners in the international community that is acting now to improve the surveillance of bird flu, modernise agricultural practices and tighten biosecurity in developing countries, particularly in south-east Asia—although we have seen in Turkey that similar help may be needed closer to home. Those basic steps could limit the opportunities for the virus to mutate further, and so stop a strain that could cause a human pandemic from emerging.
	I was delighted to see that this week, at a conference in Beijing, the World Bank received pledges from the international community for $1.9 billion to implement a global strategy to prevent H5N1 turning into a human pandemic. The bank in fact requested only $1.4 billion, which is really not a lot of money compared with the estimated cost of a pandemic—no less than $800 billion—and it is gratifying that the $1.4 billion was oversubscribed. We talked to witnesses from the United Nations Food and Agriculture Organisation and the World Health Organisation, as well as to the recently appointed UN Co-ordinator for Avian and Human Influenza, and I have to say that their evidence was extremely impressive—realistic, well-informed and based on good science. I believe that they will make effective use of the money. I understand that $250 million has been pledged by the European Commission and EU member states. I should be grateful if the Minister could tell the House how much of that the UK has contributed.
	The other way in which a global pandemic could be prevented, even if a virus better adapted to humans were to emerge, would be to identify the outbreak fast, isolate it, and saturate the area with antiviral drugs. That would not be easy in rural Vietnam or Cambodia, but we must try. Again, the WHO is doing its best to implement this strategy, but still needs more international and UK support, especially to invest in better healthcare facilities across the region, so that the first cases can get to hospital and be diagnosed before the virus has had a chance to spread out of control. This investment will pay dividends even if there is no pandemic in improving healthcare and early detection of disease threats, and I hope that the Minister will be able to give the House some indication of the steps the Government are taking to support such investment.
	If we find ourselves facing a global pandemic, what then? We would have to fall back on the Government's contingency plan, which the committee acknowledged was one of the best such plans in existence. Nevertheless, there were areas where we had serious concerns, and I would like to touch on some of those. I know that colleagues on the committee will comment in more detail on specific recommendations.
	First, there is the question of antiviral drugs, where the Government do not yet seem to have a clear policy. They have ordered 14.6 million courses of Tamiflu, enough to treat one quarter of the population, but the assumption that a pandemic would affect one quarter of the population is highly speculative. The purchasing policy also fails to take account of some evidence that antivirals would be most useful if given preventively to those who have come into contact with early cases—family members, health workers and so on—which would require many more doses. Questions about the overall effectiveness of Tamiflu have also been posed in an article in the Lancet published yesterday. We cannot afford to be locked into a "treatment-only" policy simply because that is the approach dictated by the number of doses available. The committee concluded that the Government should urgently look at the modelling of how antivirals can best be used. I hope that the Minister will respond positively to this key recommendation.
	Secondly, on health services, we concluded that there is still a lot to be done to translate the overall contingency plan into effective action at local level. In the event of a pandemic, the health service could see more than a million new cases a day. GP surgeries could see consultations rocket from 30 to 5,000-10,000 per 100,000 of the population per week. Intensive care units could find themselves expected to operate at 200 per cent capacity or more. There is a risk that the service could collapse under the strain. The evidence that we heard suggested that GPs, primary care trusts and community nurses urgently need clear guidance, and they need it now. There is no point, as the Minister told us in her oral evidence, waiting until nearer the time. I hope that the Government will take this point on board.
	We also believe that the Government need urgently to address the various barriers to effective surveillance and research in the event of a pandemic. There is still a lot that we do not know about diseases such as influenza, particularly about how best to treat them, whether with combinations of antiviral drugs, steroids, oxygen and so on. Randomised trials in the early days of a pandemic could save many lives later, but if this is to happen we need to start clearing the way now so that regulatory barriers or lack of funding do not prevent projects getting off the ground in time.
	A pandemic would also present an opportunity for profoundly important long-term research. In 1918 to 1919, the Spanish flu pandemic killed predominantly young adults rather than the very young and very old, who are affected by normal seasonal flu. Why? There are theories about excessive immune response but in reality we just do not know. A pandemic would be a once-in-a-lifetime chance for researchers to analyse why and how people die of infectious disease, but if, once a pandemic begins, they have to spend months talking to ethical clearance committees and applying for funding, the chance will be missed. I hope that the Minister will be able to reassure the House that his department is tackling this issue.
	Finally, we need strong leadership from the top. A pandemic would affect every part of society: the emergency services, schools, transport, food and fuel networks. We do not believe that the Department of Health is equipped to bring all these people together; the food retailers, for example, told us that no one from the department had contacted them. Many companies, particularly SMEs, appear to have done nothing to prepare for the possibility of a pandemic. It is in part a tribute to the efficiency of our economy that there is so little slack in the system, but that also leads to vulnerability.
	Someone needs to get a grip on these issues and ensure that all elements of society develop plans for responding to a pandemic. That is why we recommend a Minister for contingency planning, someone at Cabinet level who can take the lead and, if necessary, knock a few heads together to ensure that we have a proper, cross-departmental response to the threat.
	The same day that our report appeared—I do not know whether this was by accident or design—the Government announced the establishment of a new Cabinet committee, chaired by the Secretary of State for Health, to plan for a potential pandemic. On balance I welcome that development, but a committee, however senior, is not the same as an individual with personal responsibility. Nor is this simply a matter of pandemic influenza; other sorts of contingencies, such as terrorist attacks or extreme weather events, could raise similar issues, and that is why I believe that a Minister for contingency planning is needed. I look forward to the Minister's comments on how the effectiveness of the new Cabinet committee will be monitored.
	I indicated at the start of my speech my intention to comment briefly on developments over the past month, since we published our report. The first is the recent outbreak of H5N1 in Turkey. The situation in Turkey seems to be changing day by day. As I was preparing this speech, a WHO update dated 16 January indicated that outbreaks of H5N1 in poultry had been confirmed in 12 of the country's 81 provinces, with outbreaks in a further 20 provinces awaiting investigation. As for human cases, 20 had been confirmed, with four fatalities, all of whom were children.
	The WHO does not believe that there is any evidence of sustained human-to-human transmission, so the fact that these cases have occurred in Turkey does not in itself mean that we are any closer to a human pandemic than we were a couple of months ago. That is not to say that we should be complacent over events in Turkey. Quite apart from the threat to poultry across Europe, the fact is that the more the virus spreads through bird populations and poultry, the bigger the pool of virus and the greater the likelihood that it will mutate into a form that can trigger a human pandemic. That is why the prospect of the virus spreading to Africa is so alarming. If avian flu becomes established in Africa, by whatever means, the likelihood of a human pandemic will rise considerably.
	The second important development of recent weeks has been the report by Swedish researchers, in a paper published on 9 January, that unreported cases of sub-clinical human infection with the H5N1 virus may be widespread in south-east Asia. At the time of our inquiry we were told that there was no such evidence: if it is now emerging, the implications are profound. On the plus side, it would suggest that H5N1 is nothing like as deadly as the official figures, showing a 50 per cent mortality rate, imply. But on the other side of the equation, if there is a large pool of sub-clinical infection among human populations, the prospect of the avian virus "re-assorting" with a human influenza virus, and thus triggering a pandemic, is much increased.
	We urgently need more information on these issues, and I should be grateful for any information that the Minister can give us on the latest position. That is all I have to say at this point. I look forward to hearing what noble Lords have to say in the debate and to the Minister's reply.
	Moved, That this House takes note of the report of the Science and Technology Committee on Pandemic Influenza (4th Report, HL Paper 88).—(Lord Broers.)

Lord Mitchell: My Lords, first, I thank the noble Lord, Lord Broers, for introducing this debate so soon after our report was published. It is often said that if you want a job done well, give it to a busy man. The noble Lord, Lord Broers, is indeed that busy man and he has certainly done the job well. Your Lordships' House should commend the noble Lord for the excellent and speedy way in which he chaired and expedited this report. I have sat on several science and technology investigations and we have prepared our reports in the usual way, but this one has impressed me most in its conciseness, its comprehensiveness and its hard-hitting and well thought out conclusions.
	It was a privilege to work with the noble Lord, Lord Broers, other noble Lords and the team in the department. Of course, the subject matter helped. There was an in-built urgency in the subject of avian flu pandemic that drove the pace of this report. I hope that the Government's response will be equally timely and equally well thought out. I suspect that the comments that I received from my personal friends and colleagues on this subject reflect similar attitudes amongst the population at large. The response that I received goes something like this: "It is all hysteria cooked up by the media. Look at what happened to SARS, AIDS, BSE or foot and mouth. Look at the millennium bug or asteroids hitting the Earth; important, yes, but no need to get into a sweat implying the end of the world". They tell me, "After all, over 1 million people die each year in the world from ordinary flu. Ought we to worry about the 73 people who have died so far from H5N1?". I must admit that people who I regard in high repute have amazed me with their cynical response to this subject.
	Those of us who have been more closely involved with the dangers of the H5N1 virus are not able to share these views. Panic, we should not; but respond with some sense of urgency, we certainly should. I am concerned that the Government are not responding with such urgency and I am hoping to be reassured on that matter. The problem for us all is that there is a question that we cannot answer in the simple way that most people want. The question is "When?". When is this pandemic due to happen? The truth is, of course, as the noble Lord, Lord Broers, said, that we simply do not know. Some say, however, that it is only a matter of time. But we know that if this disease indeed goes critical, we on this planet will experience a fairly gruesome time.
	I shall confine my comments to something that we all hope will never happen—that this disease turns into a pandemic. How equipped are we to respond? The single event in our collection of evidence that alarmed me most was a PowerPoint presentation that we were shown indicating how the pandemic would spread throughout the world. We saw a map of Vietnam turning rapidly red by the day as the disease spread and how that would be repeated throughout the world. I think that I am right in saying that from the moment the virus becomes transmittable between humans and has infected 50 people in one location, it will be only a few months until the whole world is affected by a complete pandemic. It is unstoppable. If that is so, we had better be very well prepared.
	We have been told that, in our country alone, we can expect at its peak up to 1 million new incidents of the virus each day—a number that sends shivers down my spine. Such a consequence could be catastrophic for ours and every nation. To date, the only way to arrest the virus is by taking antivirals, and even that is not proved. But I would like to pose a question to the Minister. Why have we chosen to order 14 million doses of the antiviral, Tamiflu? Why not less or why not more? If the antiviral is effective, surely we need to ensure that every person in this country will be able to get the medicine. We need complete coverage, which means that every person in the country needs to be able to get the antiviral from their doctor. We need to imagine what a pandemic would look like in our own country and then what it would look like throughout the world.
	As I have said, in Britain we predict that at its peak there could be more than 1 million new cases of influenza each day. We forecast that the number of GP consultations could increase more than 1,000 times and that hospitals would be totally over-whelmed. That would be at a time when illness-related absenteeism as a result of the virus could be expected to be more than 20 per cent. The chaos that would result in our health service would be enormous. Quite simply, it would be close to collapse. The responsibility for co-ordinating the health service response in England and Wales lies with the Health Protection Agency, but its funding has been cut in recent years. Is that wise? Is it a responsible move? I would be interested in the Minister's response.
	When my honourable friend Mrs Winterton gave evidence to the sub-committee I pushed her on the subject of information systems. My background is in information technology and I have the simplistic belief that without the information and numbers, it is hard to deal with any problem, especially any problem on such a scale. I have to say that I was surprised at the Minister's somewhat vague response to my questions. So I ask again: do we have fast and effective information systems in place that will enable those people who are dealing with a pandemic to respond quickly as the situation changes?
	We make a very key point in the report, which has not readily been taken up elsewhere. If there is a pandemic, in this country we could expect 25 per cent—some people expect up to 40 per cent—of the workforce to be struck down at any time. That would include 25 per cent of people across the board: namely, 25 per cent of your Lordships' House; 25 per cent of Cabinet Ministers, policemen, teachers, doctors, nurses, cleaners or whoever; and, of course, mothers and fathers. But also it would include 25 per cent of lorry drivers who transport food to supermarkets, unloaders, stackers, checkout attendants and power workers. Throughout the nation we would be in an acute emergency. How would food be delivered? How would it be allocated? Who would risk going to a supermarket and run the risk of contagion? Yet, we would need food and other provisions. We would run the real risk of a panic and economic shutdown. And, gruesome though the subject is, anticipation that 3 per cent of all people who contract avian flu would die is another consideration that we would have to make.
	I know it is easy to get carried away and perhaps to overstate the case, but my views are coloured by the petrol crisis in 2002. We live in a world of minimal stockholding. Companies cut costs by cutting their inventories. "Just in time" is the watchword of inventory control. Of course it leads to economies of scale, which is good for business, but it also places everything on a knife-edge, which is bad when panic reigns. To me, the lesson of the petrol crisis is how fragile our economic and distribution systems are and how quickly they can all break down. Every time there is a minor threat to petrol supplies, there is panic buying. So just imagine what it would be like if there was a full-blooded pandemic? Are we prepared?
	Recently, I read that retailers and supermarket executives have been getting together and making plans for such an eventuality. Is my noble friend able to shed any light on this development? Most people in this country are employed by small and medium-sized businesses. How will these cope in an emergency? I run a company of 120 people. No one has contacted us about how we should prepare for a pandemic. Yet again, I ask: what plans do the Government have in hand to alert smaller businesses on how to cope?
	One of the recommendations we debated at length centred on government organisation to deal with a pandemic. It became clear that the Department of Health by itself was not the body to co-ordinate a national response to an outbreak of pandemic influenza. This issue is simply too wide for a department with other priorities on its plate. To us it was evident that there needs to be a cross-government initiative to deal with all aspects of an outbreak and, indeed, a person responsible across government to do so. We recommended that,
	"the development and implementation of contingency plans should be the responsibility of a Cabinet-level Minister for contingency and disaster planning located within the Cabinet Office".
	The day before our report was published, as the noble Lord, Lord Broers, has just said, there was an announcement that some government co-ordination action was being taken, but it was far from clear to me exactly what that action was. Again, can the Minister please help me to understand what organisational changes have been made within government to plan for a pandemic?
	We started our report with the statement that the United Kingdom was better prepared than most for the outbreak of a pandemic. I am sure that that is true, but we cannot afford to let matters slip. I, along with other noble Lords, I am sure, will be looking to the Minister for reassurances that, quietly but effectively, plans are in place to avoid some of the potential ravages that could well ensue.

Lord Jenkin of Roding: My Lords, I fully endorse the praise that the noble Lord, Lord Mitchell, has extended to the noble Lord, Lord Broers, for chairing the committee and the publication of this immensely important report. I see it as a wake-up call to the nation and to this House. I was not a member of the Science and Technology Select Committee, although in the past I have served on it. However, I have read a great deal of the evidence and, perhaps more important, last June as chairman of the Foundation for Science and Technology, I chaired a seminar at the Royal Society on the subject of pandemic flu.
	Not surprisingly, much of what we learned on that occasion is reflected in the Select Committee report. Indeed, one of my points is how little has changed since we heard from officials and others on that occasion. We had four speakers. The noble Baroness, Lady Finlay of Llandaff, gave a good account of what she and her colleagues were doing on the ground in west Wales. I am only sorry that she is not able to take part in this debate; she has explained to me why. We had an expert virologist with experience in Vietnam, and we had two government spokesmen: Dr David Harper, director of health protection at the Department of Health, who gave evidence for this report to the Select Committee; and Mr Bruce Mann, head of the Civil Contingencies Secretariat in the Cabinet Office.
	I must say that I was surprised to read in the report that the Cabinet Office declined to give evidence to the Select Committee. Yet when Mr Mann addressed our seminar in June, he briefly described his role as this:
	"This body is concerned with protecting people, their health, their safety, their economic well-being. If we are going to do that, much of the work will have to be delivered at regional and local level. I bring out those two points because they drive everything that we do".
	I must ask the Minister this: why did the Cabinet Office refuse to give evidence to the Select Committee when that is the statement of what it actually does?
	I note in passing that the Local Government Association also declined to give evidence. As a vice-president of that association, I have made it my business to find out why. I have received a letter from Sir Brian Briscoe, chief executive of the Local Government Association, from which I should like to quote two short passages:
	"First, let me deal with the point already raised by the Committee's report suggesting that the fact that the Local Government Association had not provided separate evidence is a matter for concern. I think there must have been some unfortunate misunderstanding. The reason we did not give evidence is because the scope of the inquiry did not seem to require a separate response from the LGA. Local authorities are completely tied into cross-agency emergency planning and response arrangements and we felt confident that the questions the Committee wished to address would be fully dealt in the Government input . . . clearly that did not happen".
	This is far too important an issue for a vital representative of the players simply not to have appeared due to an "unfortunate misunderstanding". I hope that the Minister or the noble Lord, Lord Broers, may be able to give us some explanation.
	The letter goes on to consider animal health over several paragraphs; local authorities have a considerable role and experience through the Local Authority Coordinators of Regulatory Services (LACORS), and finishes with two very brief, indeed almost curt, statements about what would happen if the bird flu virus mutates:
	"If bird flu mutates and is passed to humans, councils will work with health authorities to implement an Influenza Pandemic Plan which draws together a local multi-agency response. Plans will identify accommodation for mass treatment and establish business continuity plans to ensure key services operate during any pandemic".
	It would have been enormously helpful to the Select Committee to have heard more detail on those points from representatives of the Local Government Association. If, as I will suggest at the end of my remarks, the Select Committee maintains a watching brief over this fast-developing situation, I hope that even now they may be invited to give evidence.
	Perhaps I may return to the foundation's seminar. It is fair to point out that Dr Harper and Mr Mann had a very rough ride from an audience which contained many with experience and expertise in this field, and I have to say that they failed to reassure people that everything was being done to prepare the country. Of course we are all aware of the problem of viruses mutating and that it is impossible to have vaccines ready until you know exactly which virus you are preparing a vaccine for. That is the present state of research in this field. The Select Committee also emphasised how much uncertainty surrounds all the contingency planning and has underlined the difficulties this poses for the authorities. But it is striking how many of the strictures voiced at our seminar held last June are repeated or even elaborated in the evidence submitted to the Select Committee in October and the report published in December.
	From the foundation summary report, perhaps I may quote one paragraph:
	"Concern was expressed over what seemed to be a gulf between the planning and modelling in progress at the centre and the clinicians in primary care and other local people who would carry the main burden in an outbreak".
	By December, six months later, the Select Committee, was saying at paragraph 8.13 of the report:
	"The Government's Contingency Plan is an excellent top-level account of the United Kingdom health service response to a pandemic, but an enormous amount of work remains to be done at lower levels".
	It goes on in a similar vein.
	Because I see this as an absolutely crucial element in the plans to prepare the country in the event of a pandemic, I have read all of the relevant evidence given to the Select Committee by the witnesses who on 25 October were addressing this point, notably by Professor Pat Troop—who was in the Department of Health when I was there and is now head of the Health Protection Authority, the HPA—and others. It was very interesting but, I found, very worrying evidence to the Select Committee. I cannot possibly rehearse all the issues it raised but there seems to be a sense that all of this planning has been done down to the local level. I refer to question 89 on page 44 of the report.
	But when the noble Lord, Lord Patel—I hope I am not stealing his thunder—asked about the arrangements for getting drugs to people who are falling sick with avian flu, the answer, in which one recognises the Whitehall jargon, was:
	"That presents one of the big challenges".
	I think one recognises that a challenge is something to which no one yet has an answer.
	The witness, Dr Lightfoot, then went on to refer to the exercises being carried out, at which point the noble Lord, Lord Broers, intervened and said:
	"So you lined up hundreds of people".
	He was interrupted by Mrs Jan Hutchinson, who said:
	"No, it is a table top exercise . . . We are not playing for real".
	I find this hugely disturbing.
	Professor Troop had earlier referred to the fact that the Health Protection Agency had been commissioned by the European Union to run an exercise across the whole of Europe in the next few weeks. That was in October so perhaps it happened before Christmas. My first question to the Minister is this: do the UK exercises yet go beyond the table-top exercises described by Mrs Hutchinson? Are people now playing for real? My second question is: what about the Europe-wide exercise? Has it happened? What lessons were learnt? Was it, too, merely a table-top exercise? If the gulf—I use that word again—between the centre and the field is to be bridged, surely people need to practise for real how this is going to be done.
	Noble Lords will remember that there was a real practice of a major event on the Underground, which was very disturbing because nothing seemed to work. But the lessons were learnt and so, when we had the bombs in July, the response was dramatic and absolutely outstanding. But it was the practice—not a table-top exercise—that had shown people what needed to be done.
	Another issue—and here I pick up a point made by the noble Lord, Lord Mitchell—concerns the dissemination of information to and guidance for the public. It is common ground that the worst case scenario envisages such huge numbers of people succumbing to the virus, with such a high death toll, that the health service would be overwhelmed. The noble Lord, Lord Broers, gave some examples of this. At the foundation's event, some people argued that this would place an enormous premium on communication and that someone would be needed to take the lead and act as a public focus for a widespread information and advice programme. The Select Committee heard the same evidence from Dr Nabarro, the Senior UN Co-ordinator for Avian and Human Influenza. It is reflected in the Select Committee's recommendation at paragraph 8.16, which states:
	"All departments of Government need to work together in preparing for a possible pandemic, but we do not believe the Department of Health can provide strong enough leadership to achieve this".
	As the noble Lord, Lord Broers, said, it then went on to refer to the need for a Cabinet-level Minister.
	I, too, hope that the Minister will now elaborate. Yes, there is going to be a MISC Cabinet Committee—and those of us who have served in government know that MISCs come and go—but who will be chairing it? Will that person have an overt public duty to lead the country on this important issue? Is the Select Committee's recommendation for a Cabinet-level Minister the subject of a serious study in Whitehall? I hope the Minister can reassure us on that.
	What about the messages that are to be given? I shall not rehearse the evidence of Mr Kevin Hawkins of the British Retail Consortium and others because it is well described in paragraphs 6.29 and 6.37 of the report. He recounted the apparent lack of preparedness of the business community, a matter to which the noble Lord, Lord Broers, referred. The Select Committee described the evidence as,
	"probably the most alarming that we heard in the course of our inquiry".
	It said:
	"Attempts to plan for such contingencies"—
	a shortage of staff and heavy goods vehicle drivers, panic buying and so on—
	"have not had much encouragement from the Government".
	My own straw poll of oil companies at a recent event downstairs reinforced this. Some of the off-shore companies have made provision for reserve helicopter pilots, but they could not tell me of any companies which have got a proper distribution arrangement for tanker drivers. I hope to hear more about that.
	I turn now to the Government's input into the inquiry. The evidence given by Ms Rosie Winterton, the Minister of State, served simply to reinforce the impression that no one is in charge. She saw her duty as doing little more than explaining what her officials were up to. I found her evidence far from reassuring. We await the Government's response, both today and in their formal reply.
	As I said earlier, I hope that the Select Committee will decide to keep a continuing watching brief on what the noble Lord, Lord Broers, has said is a fast-developing situation. I congratulate the noble Lord and his colleagues on a very necessary piece of work, but it is the beginning and not the end of effective scrutiny.
	I end with one more quote:
	"Most experts believe that it is not a question of whether there will be another severe influenza pandemic but when".
	That was said by the Chief Medical Officer four years ago in 2002. This report must be a wake-up call.

Baroness Sharp of Guildford: My Lords, I join others in paying tribute to our chairman, the noble Lord, Lord Broers, in bringing this inquiry and expediting it through the Select Committee. We decided to undertake this inquiry last June/July but we did not take any evidence until the beginning of October. As an economist, not a scientist, I came to it uncertain quite what to expect. In the summer I was highly alarmed by the headlines then in the newspapers of the possibility of a pandemic hitting us this winter. Like many others, I was, in my bones, well aware that we were anything but ready to cope with such a pandemic.
	In one sense, I found the experience of going through the inquiry reassuring. Most noble Lords who have spoken so far have referred to the difficulties they foresee in meeting a pandemic. What reassured me—and I shall come back to this later—was that the chances of our being hit by the pandemic this winter did not seem likely and there was time to plan. However, I share the view of the rest of the committee and of those who have spoken so far, particularly the noble Lord, Lord Jenkin, regarding the Government's complacency that what they have already done has been sufficient and the failure of lateral thinking.
	I return to why I was somewhat reassured by what we heard. We began the inquiry in earnest in October at a time when the geese were migrating from Siberia to Ukraine, Bulgaria, Romania and eastern Turkey. There was a lot of tabloid hype, but we learnt that we were at some point likely to see pandemic flu sweeping the world and it was likely to emerge from a mutation of avian strains of flu, as had happened in previous pandemics. The current strain of H5N1 avian flu which has been circulating in Asia since 2003 is a particularly vicious strain. But the key to its emergence as pandemic influenza in human beings is when the virus shifts from the current avian strain which has so far infected only those humans who have had very close contact with birds to a virus which can be passed from human to human. So far, that has not happened. There are only two known possible cases of human-to-human transfer, both in Vietnam, where a family member nursed another family member.
	While there is a particularly vicious strain of avian flu circulating in the bird population of Asia and migrating birds will spread it to other areas, it has so far stuck to birds and it has not mutated to a human form of pandemic influenza. The chances of it mutating are greater, and the greater the degree to which avian flu becomes endemic in the poultry population, especially of a country such as China, with its vast population of chickens—I gather that there are 700 million ducks in China, in most cases living cheek by jowl with other people—

Baroness Sharp of Guildford: My Lords, I meant that the ducks live cheek by jowl with the population of China, particularly in the countryside.
	The front line of defence is therefore to try to snuff out outbreaks of avian flu wherever they occur. We saw that happen the first time the new strain struck, which was in Hong Kong in 1997. It was effectively eradicated. In 2004, Thailand—a middling developing country—has managed effectively to eradicate it. But that is very much more difficult in countries such as Indonesia and Vietnam which are extremely poor. We have seen how difficult it has been for Turkey to cope with the problem that has hit it. That is why the FAO follows up progress. As we have seen in Turkey, it follows domestic teams and monitors the effectiveness of the culling process in all the countries where the problem strikes. That is why the committee was so shocked to learn that at the time we interviewed the FAO, it had only some £25 million to $30 million in hand to undertake this sort of work, as compared with the $160 million it had asked for. The really good news of the past two days has been the outcome of the Beijing conference. The FAO asked for $1.5 billion and has in fact been over-subscribed. It has succeeded in raising $1.9 billion.
	The key is whether farmers can be compensated for the poultry they have lost. For many of these poor people, poultry is all they have. They will not say, "I have a dozen chickens just round the corner" unless they know that they will be compensated. If they are not, despite all the Turkish or Vietnamese soldiers sent in to make the cull, they will try to hide their poultry. In that case, avian flu cannot be eradicated.
	The extremely good news from Beijing raises the possibility that we can snuff this out right at the beginning. As the noble Lord, Lord Broers, said, one of our chapter sub-headings was entitled Prevention is better than cure. The recent outbreak in Turkey illustrates very well how easy it is for avian flu to break out and how difficult it is to contain it unless the local population are aware of and alive to its dangers. I do not know how many noble Lords saw the television broadcasts from Turkey, but I caught one or two. The three children who died had apparently been playing ball with the heads of dead chickens, the blood got on their hands and then they were eating. Almost inevitably, the children picked up the H5N1 strain, avian flu. In another case, a little girl had come home from school to discover that her pet chicken was unwell and she said, "I hugged it".
	It is not surprising that the FAO has to send in teams to monitor the problem. Turkey seems to have had some real problems in coping with the spread of the disease. It is vital that the FAO uses some of the money to make sure that we snuff it out in Turkey. It is, after all, as affluent or as relatively developed as Thailand, and if it can be done in Thailand they ought to be able to do it in Turkey.
	The Turkish experience also illustrates how important it is to monitor the mutation of the virus itself. This is where our own National Institute for Medical Research comes in to the front line. It is working for the WHO in defining the genetic structure of these strains. Here there are causes for concern. The Turkish gene sequences incorporate two changes which make human infection more likely. They have been seen separately before but never together.
	As the noble Lord, Lord Mitchell, said, at some point—this year, next year, sometime, never—it is quite possible that mutation will take place and we will be hit by pandemic flu, passing from human to human. As the noble Lord, Lord Jenkin, said, the danger of that mutation taking place in Africa, given the problem of AIDS, is very real. It is important that help is given to Africa if the disease breaks out there.
	The message is that if the virus is quickly identified and the cluster of those carrying it is effectively isolated, it might, like the SARS virus, be snuffed out very quickly. But if it gets into the wider population—like SARS, it will be highly infectious—and given travel patterns around the globe, it will be extremely difficult to contain.
	As noble Lords have indicated, our key concern was to see how prepared Britain was for an outbreak of pandemic flu, should it occur. We found that a good deal of planning had taken place, especially in the health service, and that the UK was regarded as one of the few countries in the world that had put serious thought into how to handle such a crisis. Nevertheless we were concerned that, even in the health service, not enough lateral thinking had been undertaken. For example, how would GPs' surgeries cope when inundated with cases or suspected cases? Were GPs expected to give up all other duties? Were performance indicators going to be dropped? Given the present state of turbulence in the NHS and with the new reforms being rolled out, many of us were very sceptical that the NHS would be able to cope.
	We came to the conclusion, too, that at present regional and local planning was only skin deep. Yes, there were these splendid things called Regional Resilience Forums, which had been set up, and which had all had grand meetings and talked about grand plans, but we got the impression that that was about as far as the real contingency planning went, and that to date very little had been done to talk to people on the ground, let alone start co-ordinating actions or establishing priorities. For example, were schools to close and, if so, at what point within the pandemic would they close?
	Furthermore, it seemed that very little lateral thinking had been done by government departments themselves. We were, for example, struck by the degree to which no one had given thought to how absenteeism might hit all kinds of services, including fuel and food supply links. As the noble Lord, Lord Mitchell, said, absenteeism could be as high as 25 per cent.
	Above all, we were struck by the uncertainties created by the two main strategies for fighting the flu itself. As regards the first line of defence, the antiviral drugs that were to be used to treat the first cases and to provide prophylactic protection for health workers and those who came into close contact with those first cases, it was very unclear how far the government order of 14.6 million courses of Tamiflu was supposed to stretch, especially if, in order to be effective, more than one course of treatment was required. If taken preventively, one course lasts for five days; so front-line staff might need successive courses. Equally, treating patients and their families would rapidly eat into those courses—at the rate of 1 million a day into the 14.6 million stockpile. No clear priorities seem to have been given. What is the specific strategy if Tamiflu proves ineffective or requires larger doses and longer treatment than they have allowed for?
	The second line of defence is vaccines. It is clear that until the pandemic virus has been identified, no vaccine can be developed—and we all understand that. Further, using the current egg-based technology for vaccine production, it would take at least seven or nine months from the initial outbreak of pandemic influenza to prepare such a vaccine, by which time, if the 1957 or 1968 outbreaks are the pattern to go by, the pandemic will have passed its peak. The Government told us that they were negotiating an advance purchase agreement with Chiron, their main vaccine supplier, for 120 million doses of vaccine, two for each inhabitant of the UK, but I have a number of questions to put to the Minister about that.
	First, given the relatively large doses of vaccine required for the H5N1 type of virus as distinct from the normal flu virus—and I gather that you need at least four times as much as for the normal flu virus—and given maximum global capacity for production of an egg-based adjuvanted vaccine that is enough to cover a population of 225 million, which is approximately the population of the US, is it really feasible for the UK to pre-empt 25 per cent of that capacity?
	Secondly, since the Sanofi experiments using an adjuvant proved on the whole to be rather unsatisfactory, and given the disappointing results, why did the Government reject the advice that they were given over a year ago, at the beginning of 2005, to find an independent adjuvant study?
	Lastly and perhaps most importantly, why have the Government not supported accelerated trials for an emergency DNA vaccine—the UK leads in their delivery and has the capacity; and using existing bio-pharmaceutical facilities—to make it in a relatively short production cycle? We were in the lead on this, and we now know that the Americans are putting $2.8 billion into it. We could have contributed considerably to that at an earlier point. Why did we not do so?

Lord Giddens: My Lords, I echo the congratulations that other noble Lords have offered to the noble Lord, Lord Broers, and to his committee on producing the report. The noble Lord entered your Lordships' House later than me and is therefore a lot more energetic. I totter along to a few debates. However, the noble Lord has not only sat on a committee but chaired one and, as everyone can see, has done so magnificently. The report is exemplary. The fact that a report of such precision and clarity has been produced by Members of this House makes me proud to be a Member of it. Your Lordships' reports tend to disappear into a void, no matter how good they are, but we must hope that that does not happen with this one.
	I am not a medical expert but I have spent a good deal of my career studying risk and I wish to contribute to the debate from that angle. It has already been mentioned that influenza pandemics go back well into history. I believe that the term "influenza" was coined in the 15th century. At that time it was the Italian word for influence. It seems an appropriate term for the disease, although the influence referred to celestial malign influence rather than to a disease which can be passed on through influence from one person to another.
	I want to consider in some detail the 1918–19 flu pandemic as that has figured so much in newspaper reports and other discussions of the possible implications of a pandemic occurring today. We have a great deal of material on the pandemic, especially in the form of new social history, which I find very interesting. It is also worth pondering the relevant contrasts. The 1918–19 flu pandemic was widely known as Spanish flu because one of the first reports of it emanated from Madrid and one of its first known outbreaks occurred there, although that was not a lethal outbreak. It occurred before people understood the lethal nature of the disease or, indeed, it might not have mutated by that time.
	Nations being what they are, the Spanish did not like to call it Spanish flu, just as we do not like to use English terms to describe our deviant sexual practices—we use French terms. The French in turn use English terms. The Spanish called Spanish flu the "Naples soldier".
	We know a lot but there is much that we do not know about the 1918–19 pandemic. There are wild differences in the estimates of how many people died from it. The lowest estimate suggests that about 20 million people across the world died. You will see stated everywhere in the literature, of which I have read a lot, that this is more than the number of people who died in the First World War. That may be the case but I do not think that we know. The highest estimate is much higher, at 100 million people across the world who died in the pandemic, but I think all these are pure guesstimates. Some say that a fifth of the world's population was affected, some say a half. But, whatever way one looks at it, this was an amazing episode in relatively recent human history.
	An amazing "Jurassic Park" moment occurred too, which I am sure the medical experts here will know a lot about. Genetic material from a dead soldier was brilliantly reconstructed using scientific innovations and was then introduced into mice. The lethal nature of the flu was shown to be 100 times greater than that of an ordinary human influenza virus. It was almost certainly a form of avian virus which adapted to human beings and was then passed on between them.
	People were killed in every continent and therefore it was a global pandemic. The highest proportion of people affected died in India, probably because of relatively insanitary conditions in that country. Some famous people died—for example, Ergon Schile, one of the Sezession painters. I refer to the marvellous Klimt paintings in Vienna in that regard. Schile died young as a result of the influenza pandemic.
	What do we know about the pandemic? As has been said, it affected people from very different age groups. So far as I can tell, no one is quite sure why that was the case. Social historians have unearthed a lot of horrifying contemporary descriptions. It seems that healthy people could die in well under 48 hours. You could be a healthy young person but be dead, some say, within 24 hours. Doctors recorded such cases. Originally, many of the cases occurred in military camps so they were closely observed, and then there was a second wave—a civilian wave. A doctor stated that patients he observed,
	"died struggling to clear their airways of a blood tinged with froth that gushed from their nose and mouth".
	The old nursery rhyme, "Ring of Roses", famously originated at the time of the Black Death. At the time of the pandemic children had their own skipping song, which went:
	"I had a little bird, its name was Enza, I opened up the window, and in-flew-Enza".
	Great poetry it is not, but one gets the idea.
	Looking at what happened, you have to ask how instructive it is for us and what the differences are. I believe that the differences are profound. First, it is better to consider what happened in the US rather than in Europe because the US was more of a civilian society at that time, and therefore the situation there is more analogous to what would happen now should a pandemic occur, whereas Europe comprised a war-torn society. There were panics, a breakdown of social order and an upsurge of violence in a number of US cities. There was a great deal of emotional flux in communities where there was a fairly high incidence of cases. One should note the importance of rumour in these situations. A rumour went round some parts of the United States that dogs were carriers of the flu and people started to put their own and other people's dogs to death on the basis of a completely false rumour.
	Secondly, governments did not tell people the truth. I am pleased that this Government—and now the American Government—are trying to tell people the truth, but I will come back to the complexity of that later because telling the truth about risk is not a simple matter. The surgeon-general of the United States tried to persuade citizens that the virus was no worse than ordinary influenza. Such statements have resonances of what happened here when BSE—mad cow disease—emerged. Those sort of statements start panics; they do not stop them.
	Thirdly, it was notable that most people reacted stoically to the original pandemic. Panics were relatively rare. However, people did not have relevant information and did not know what to do. Historians describe touching dilemmas. Members of one family wondered whether they should visit their infected daughter who was living on her own. They asked, "What should I do? What should a family do in such circumstances?". It was not clear to people. It is not completely clear to me what one should do. Presumably, one should arm oneself with protection before visiting an infected person. However, at that time it was not at all clear what should happen, so there was a lot of everyday social and moral confusion with very significant consequences for mortality as people did not receive the care that they might have done from other family members.
	As I say, this was an amazing episode. It was ill-publicised at the time. It was dug out mainly by later social historians. It did not receive a lot of press attention, largely because of the war but also because of the build-up to peace. President Wilson was busy making peace when this happened in the United States, and the amount of publicity that it got, given that it was an extraordinary global pandemic, was remarkably small.
	What can we learn from that episode, leaving aside the medical aspects? First, we have to see that the situation is very different now, and therefore some of the comparisons that people make with the 1918–19 pandemic should be treated with caution, but some of the comparisons are the worse for us. First, if there was a pandemic of the kind so well described in the report, it would be the most significant single episode of loss of life of a specific set of occurrences outside of war or outside of situations of deliberate genocide. We just do not know how the world would handle a situation like that.
	Secondly, there is something quite different to 1918–19, which is the pace of news and the universality of news. Would that situation further foster rumour, or would it serve to reduce rumour? That is not completely clear. Thirdly, we obviously have better medical technologies, but we also have advance warning. This is the first time when there would be a pandemic of which we had advance warning; so I support the report when it says that we should try to block the whole thing at source if we possibly can. We have to assume, however, that in a globalised world we may not be able to do that; the very things that allow us to have a more effective response are also the things that make that response possibly ineffective.
	I conclude with a few observations that I ask the Minister to bear in mind, and perhaps he could comment on one or two of them. They do bear a bit on the sorts of comments made earlier by my noble friend Lord Mitchell. First, we know very little about the moral psychology of a society in a televisual age. We just do not know what kinds of panic phenomena could develop in such a society. We know that this society is quite an emotionally febrile one. It may seem farfetched, but I ask noble Lords to consider what happened with the Diana phenomenon. No one quite understands how that happened, where those emotions came from and where they went to. Suppose those emotions were harnessed on fear or on anxiety, and perhaps consolidated around aggression. That would be a truly formidable problem.
	Secondly, the Government must be alert to the perversities of risk management. My noble friend Lord Mitchell said something about questions that we cannot answer. When we are discussing risks, by definition we cannot answer the questions. All we can say is, "This is the current situation of our knowledge about risk at this particular time". A risk means that you do not know what will happen. The risk of a pandemic is not like the risk that insurance companies cover when you drive a car; every time you drive a car you can calculate the actual statistical risk that you will have an accident. You cannot do that with an imminent pandemic.
	Therefore, it is very difficult to manage such risk situations. You have an oscillation between accusations of cover-up on the one hand if you get one kind of analysis wrong, and scaremongering on the other. It is even more perverse than that because in a sense you have to scaremonger to get people to take the risk seriously. Suppose there is no significant episode of avian flu, people will say, "Why did you scare us so much in the first place?", forgetting that the scaring mechanism is part of the way in which the world community responded. Those things are very difficult to manage. I have already noted down quite a few sceptics who were using the example of swine flu in 1976, when it was said that 1 million people might die in the US. How many people died? One person; so that was out by 999,999. People are now saying that Tamiflu and Relenza might not work; that is the other side of this risk management situation. The Government should be alert to the subtleties of it; it is not as simple as simply telling people the truth. It is much more difficult to manage than that.
	I shall move quickly to my last point. I had some interesting stuff to say about living in a risk society, which is the sociological notion of living in a society when you have many new kinds of risks, which come from sources that you do not understand. They are not like risks from Nazi Germany—they are much more diffuse risks, which are very difficult to live with. I will tell a joke in finishing from Private Eye. I do not know how many noble Lords here have dissolute backgrounds like me, but they might remember the Who's "My Generation", where they sang the line:
	"I hope I die before I get old".
	In the cartoon, there is a kid walking past a billboard abut avian flu, the tsunami, global terrorism and global warming, and he says, "I hope I get old before I die".
	We must deal with the convergence of risks, which is the point that my noble friend Lord Mitchell made and on which I was going to elaborate. We live in a just-in-time society; that is very new. The Government must have joined-up thinking on the risk issue; they must. The Prime Minister and the Chancellor are always saying, "Let us be a beacon to the world"; let us try to be a beacon to the world in respect of risk prevention too.

Baroness Byford: My Lords, I, too, congratulate and thank the noble Lord, Lord Broers, and his committee for their challenging report that we are debating today. As other noble Lords have said, the report acknowledges that the UK remains among the best prepared countries in the developed world, but it also poses questions on how that preparedness can be improved. Listening to my noble friend Lord Jenkin of Roding, I wonder how much of that preparedness is in theory and table-top, and how much is actually practised on the ground.
	I read with interest the National Health Service report UK Influenza Pandemic Contingency Plan of October 2005, as it seemed sensible to read the two reports together. It was also interesting to compare some of their findings. Both reports recognise the importance of strong leadership, good organisation, co-ordination between departments, clear lines of accountability, and communication as the key to preparing for and the response to a pandemic. However good our internal planning and strategy are, good communication, as the noble Lord, Lord Giddens, has just said, is vital. We live in a society when you can find out what is going on anywhere in the world at any particular moment; the pace of news coverage is quite frightening. When we had to deal with the foot and mouth outbreak, at one stage the general public were restricted from going into certain areas of the countryside, which were uninfected. Later, it was decided that the restriction was not necessary. It is a small example compared to a pandemic, where the need would be greater, but it highlights the difficulties of decisions being taken between departments and about which department is in the lead, to which I shall return later.
	Also important for the general public, if there is an outbreak, is whether vaccination will be needed and whether they will they qualify for it. They will also need to be assured about why certain people are getting support and help, through vaccination or in other ways, when it is not generally available to everyone. The need to manage those expectations is touched on by the report. Do the Government have a list of priority people, as referred to earlier by the right reverend Prelate, who are considered the No. 1 key workers? Perhaps the Minister could tell us more about that.
	Defra is normally my responsibility, but today's debate and what we do on the Defra side are very much linked. Avian flu, as has been stated already, is a disease of birds and not of humans but, as the outbreak in Turkey has shown, the very close link between birds that are infected and humans is critical. I was pleased, when I introduced a debate last autumn on avian flu, that several noble Lords spoke purely from the health aspect. I hope my contribution today will slightly overlap. Both aspects describe the need for a single lead. In the chapter titled "Prevention is better than cure", the report reminds us that avian flu is a disease of birds. I think that the general public is still not aware of that, and it is a responsibility that the Government need to address, otherwise people will panic unnecessarily.
	There is much to be done in some areas abroad—in south-east Asia and recently in Turkey, where the looking-after of poultry, as the noble Baroness, Lady Sharp, said, is very much part of people's daily lives as they live in such close proximity. That does not occur here. When I visit poultry outlets the biosecurity that takes place there now, even before the outbreaks, is very high. But in those areas of the world where such issues are not addressed, there is a great deal that we can do to help.
	I wish to highlight two matters in relation to that. One is the need to improve the veterinary infrastructures, which would enable greater co-ordination in the exchange of information, because I suspect that it does not exist in many countries. The second, which has already been mentioned, is the lack of compensation arrangements for farmers in those countries. Dr David Nabarro acknowledged that we are not winning the battle in the severely affected countries. The only global organisation that has the potential penetration to improve the situation is the food agricultural organisation of the United Nations, which has been underfunded. I suspect other noble Lords will refer to the whole question of underfunding.
	Lack of resources is a theme that runs through the report. The calls for Health Protection Agency funding to be reviewed and the recent cuts to be reassessed and reversed are there to be seen and I hope that the Minister will respond. The report calls on the Government to extend the funding to the surveillance operations of the Royal College of General Practitioners. I would like the Government to comment on what they have done.
	The Minister will no doubt tell us that the Government have many demands on their purse. Indeed, they have. Whatever the needs, decisions that should be taken must be proportionate and practical if we are to cope with any future outbreaks. Many noble Lords have asked, and it was demanded in the report, that a single person take a lead if there is a pandemic outbreak in the United Kingdom. The report calls for a Cabinet-level Minister to be responsible for contingency and disaster planning, located in the Cabinet Office. Has that suggestion been taken up and is he now called the Minister of homeland security, which our party called for last year?
	Has a direct link been established between Defra and the Department of Health regarding the protection of people who work with poultry or on pig farms, who are most likely to be caught up in the first instance if avian flu breaks out again in this country? Has the Government's emergency strategy put in place a system to cope with the likelihood of serious disruption to food supplies? Why have they not had discussions with major food retailers? Heaven forbid that we should have a major outbreak, but it is likely that the normal way that society works will fail and be unable to continue in the way that we know—economically and in relation to distribution, for example.
	Is the Minister satisfied that plans at local government level are adequate? My noble friend Lord Jenkin said that local authorities were not even included in evidence to the report. The report reflects that the committee was not convinced that local government was yet fully aware of the implications of a pandemic. Is that also true of local hospitals and homes, particularly those who care for the elderly, who may be the most vulnerable?
	Working towards the prevention of an outbreak must be given the highest priority. This country has some of the best scientists, whose research and skills are of benefit not only to us but internationally. Time after time funding has been reduced. What are the Government going to do about that and what priorities do they place on our skills and ability to help others throughout the world?
	Vigilance is important, and the coming months of the migratory bird season are a time when we really must be aware and keep our eye on the ball. Avian flu has occurred only once here recently, but it is possible that the influence of wild birds coming over our shores may well raise the risk to a crucial level. We need to be vigilant.
	This report posed the Minister many questions and, having read it, I hope that he will answer them directly and not use the excuse that the Government have not had time. The report was printed on 16 December and it is time that we had a direct response from the Minister. I hope that he will not disappoint us, because, in such debates, we are often told that the Minister will reply in writing. But that means that it does not appear in the Official Report and it is extremely important that the work of the committee is in the public domain and that members of the public can look at it.
	I am most grateful to the noble Lord, Lord Broers, and his committee, and I give it a challenge: will it please continue to keep a brief on this issue? Would they make it slightly more cross-departmental, because the work within Defra and the work that I undertake would be important in addition to the contributions from those who gave evidence in this report. I await the Minister's reply with great interest.

Lord Patel: My Lords, I thank the noble Lord, Lord Broers, for his excellent chairmanship of the committee, of which it was a pleasure to be a member. I also thank our specialist adviser, Professor Julius Weinberg, the Clerk of the committee, Dr Christopher Johnson, and the scientific adviser, Jonathan Radcliffe.
	We are debating an important issue, for we know that a pandemic influenza will occur. We do not know when, although recent events suggest that we might be closer to it. We do not know how severe it will be, but we know that if the worst-case scenario occurred it would change the whole fabric of our society and would be devastating, particularly to the developing world. What the public need, therefore, is an assurance that the Government's plans of coping with the pandemic will reduce the risks to the population.
	I wish to address two aspects of the Government's plans—the strategy for the stockpiling and use of antivirals and the plans for vaccine use. Before I do so, it might be helpful to put matters in context and comment on what we know. We know that flu regularly kills 100 to 200 people per million every year—mostly the elderly—but that the majority of people who are infected recover and develop immunity to that strain of the virus. Every now and again, however, a flu virus appears with surface protein that is different, so that the immunity acquired from previous infections does not help. It is a pandemic caused by such a virus that we fear. Some of the new viruses are more deadly than others. Right now, we are worried, because one strain of the virus H5N1, called the Z genotype, has now appeared with deadly effect in domestic fowl and has been able to infect people, again with deadly effect, although the human cases hitherto are still rare.
	What the scientific community fears is that the virus will undergo further changes and evolve into a form that is capable of spreading from person to person and causing a worldwide pandemic. It is possible that the last stage in the evolution of the virus, enabling it to spread from human to human, will occur in infected humans. Therefore, as the number of people infected rises, it is more likely that such a mutation will occur. For that reason, the UK Government need to play a strong role, and provide the necessary assistance, in helping to control the spread of the virus, both in domestic fowl and humans, in whichever part of the world it occurs. That is particularly the case in the developing world, where people rely on domestic fowl for their livelihood and where, if the birds are slaughtered or culled, people are not compensated.
	If there is such a worldwide co-ordination of efforts, as Dr David Nabarro of the United Nations asked for in his evidence, we may—just may—nip the pandemic in the bud and prevent it from becoming a global disaster. Can the Minister tell the House what the United Kingdom Government are doing to assist in such a global co-operation?
	Many of the Government's efforts are aimed at minimising the effects of the pandemic on the UK population. I commend the Government for having a plan, recently updated, that is regarded as one of the best in the world. But events are moving fast and, as we acquire more knowledge of how the virus is behaving, the plans need to be modified. In the United States, President George Bush has announced a $7 billion investment for vaccine development and the stockpiling of drugs. Other countries, such as France, Canada and Singapore, have updated their plans, which go beyond ours in terms of the level of stockpiling of antivirals and vaccines.
	I want to comment on two aspects of the Government's plan—one related to the use of antivirals and the second to the use of vaccines. The 1918 pandemic, when 98 per cent of the world's population were exposed to the virus, resulted in over 25 per cent of the people becoming sick and 3 per cent of them dying. An estimated 40 million people were affected—1 per cent of the then known population of the world. The death rate was much lower in the two subsequent pandemics of 1957 and 1968, when 1 million to 2 million people died. That was because the H5N1 virus that caused the pandemic in 1918 was different from the human flu strain that caused the pandemics in 1957 and 1968. If the pandemic that we fear is caused by the current strain of H5N1, if the virus remains as virulent as it is now and if a third of the world's population get sick, in the worst-case scenario between 3 and 10 per cent of the world's population will die.
	I come to the Government's strategy for mitigating the effects of the pandemic in the United Kingdom. The key strand is the Government's strategy of stockpiling the neuraminidase inhibitor drug, Oseltamivir or Tamiflu. The Government intend to stockpile 14.6 million doses of the drug to be used for the treatment of the estimated 25 per cent of the population that will acquire the infection.
	There are several imponderables. How confident can we be that the virus will not affect more of the population? Neuraminidase inhibitor drugs are most effective when given within the first 48 hours of the symptoms and signs of the viral infection appearing. That means that we have to be confident of our ability to diagnose the infection early and to get the drugs distributed to those in need in time. Unless we have a specific rapid test that identifies infection related to the pandemic virus, many in the population who get flu-like symptoms, but not the pandemic flu, will believe that they have acquired the infection and will demand drugs. Can the Minister assure the House that the Government have the strategy in place to cope with that?
	I understand that every country in the world is now trying to stockpile the antiviral drug Oseltamivir. There are problems of production capacity, although that is likely to improve slightly once Vietnam and India begin to produce the drug. However, should the Government not look again to ensure that our current level of 14.6 million doses will be adequate, particularly as some evidence is emerging that suggests that higher doses of the drug than originally thought will be required? Should not the Government also consider stockpiling other neuraminidase inhibitor drugs, such as zanamivir or Relenza, or even the adamantane group of drugs? Hitherto, it has been considered that the virus has been resistant to those drugs when given to chickens, but the new virus that may emerge may not be resistant to them.
	I now briefly come to the strategy related to vaccines. Until the pandemic starts, we will not know the exact strain of the virus and thus will not be able to begin to produce a specific vaccine. As other noble Lords have said, by the time the vaccine is available, it will be too late for those who got the infection in the first wave, except for those who are lucky enough to survive, who will then have some immunity and may even be a useful source of plasma.
	The Government are stockpiling 2 million doses of vaccine against the existing strain of H5N1 to be used in the vaccination of key front-line workers, who will be identified at the start of the pandemic. Will that be too late? With 25 per cent of the population at risk of being sick from the infection, that strategy is based on the hope that, if the virus that causes the pandemic is not too different from the current strain, the vaccine will provide some immunity. We know that in the long term mass vaccination, and not antivirals, will be the best protection. Why are the Government not considering the mass vaccination of the whole population against the current strain of H5N1, as strongly suggested by Professor Hugh Pennington, president of the Society for General Microbiology?
	I know that the arguments put forward against that will be that the virus that causes the pandemic could be different and that, if the pandemic did not occur, some people would have suffered unnecessarily from the adverse effects of vaccination. The answer could be to stockpile the vaccine and use it once the pandemic starts because then the risk would become acceptable. Of course, there will also be a need for the Government to suspend some of the regulatory considerations related to the production and testing of vaccines, which will have to be addressed in a global context. For example, the Government could help to pilot such a project in south-east Asia, where the population is at greater risk, to determine the efficacy of such a policy. I realise that my suggestions in relation to the greater stockpiling of both antivirals and vaccine would be expensive and would require increased production capacity, but all insurance is expensive.
	Finally, perhaps I may refer briefly to the important issue, even at this stage, of planning for the pandemic in terms of the programme of research related to the use of antivirals and vaccines and epidemiological and clinical research. All that requires advanced planning, as the Academy of Medical Sciences and the Medical Research Council told us in their evidence to the committee. Again, some areas of research will require suspending the regulatory mechanism that usually has to be followed. I hope that we will soon see these research issues being addressed. Perhaps the Department of Health and the research bodies should work together to start that.
	In conclusion, I reiterate that there is much on which to commend the Government in relation to their plan for the pandemic, but some important issues remain to be addressed if we are to reduce the effect of the pandemic in the United Kingdom. I look forward to the Minister's response.

Lord Winston: My Lords, it is a pleasure for me to pay tribute to our chairman the noble Lord, Lord Broers, who conducted this inquiry with impeccable chairmanship. I also thank our specialist adviser, Professor Julius Weinberg, and our clerk, Christopher Johnson, who were extraordinarily helpful during what was a relatively brief but difficult inquiry.
	If one takes all the risks that scientists reckon might threaten mankind—which would certainly include global warming, nuclear accident and collision with an asteroid or a planet—there is no question that infection must come very high on the list. It is a source of worry that in general our ability to combat infection is by no means total. It is true to say that no new antibiotics have been developed for probably two decades. Most of the antibiotics that we use come from quite old technology and there is certainly a problem there. As we have heard today, viruses are particularly nasty because they have a habit of mutating. Sometimes that is an advantage to us, but it is difficult to predict.
	I ask my noble friend, Lord Warner, to break with tradition—at least as far as I am concerned—and be kind enough to answer one or two questions that I put to him during the debate. As a committee, we were particularly perturbed during the evidence of the Minister, Rosie Winterton. Frankly, most of us felt that the evidence that we received was, to say the least, somewhat complacent. There are a number of unanswered questions that I would like to put to the Minister and it would be helpful if we could have him address some of the answers today and perhaps the rest in writing. There is a real need to take this very seriously. Of course, we all accept that the risk of a pandemic is small, but if it occurred there is unquestionable evidence that it would be disastrous.
	I want to concentrate on one aspect of the report: the evidence on pages 87 to 103. At the beginning of the Minister's comments—they are interesting because they are relevant to communication—she said that the recent media coverage has shown how important it is for us to redouble our efforts to ensure that the media are aware of the true situation. I understand that that is quite a difficult thing to do. I would like to know how the Government envisage that public engagement. It is almost three months since that evidence was given to us on 1 November and I am not entirely convinced that there is any more public awareness of the situation nor indeed any media awareness. Recent events in Turkey are very worrying indeed. Should, by some horrible chance, there be the first evidence of human-to-human transmission, no doubt there would be serious panic, as my noble friend Lord Giddens has already mentioned.
	My second question refers to the issue of the 120 million doses of vaccine. If we saw human-to-human transmission, would we be able to get those doses immediately? How soon could that be done? The Minister also said in her evidence that £200 million was being spent by the Department of Health on antivirals. That is a considerable amount of money, but it was not clear to me how much of that might be spent, for example, on antivirals used for, let us say, HIV and how much would be used specifically for a flu epidemic of this kind. I would be very grateful if we could have that evidence so that we can assess that this afternoon.
	The Minister also talked about £25 million being spent on communication plans. Can we learn a little more about exactly what those communication plans might be? That might be quite a complicated point to answer this afternoon, but I think it would be helpful to know more about them. One matter that deeply concerns us as physicians and scientists is that so often—as happened, for example, with the foot and mouth outbreak and with CJD—again and again scientists get the blame for something that is actually not their fault. That is a very serious problem now because, as the Government recognise, the need for better public engagement and the need for better public dialogue in a scientifically literate and technologically advanced society is paramount. There is a very real risk that science can be brought into disrepute and, if it is brought into disrepute now by, for example, a mishandling of an epidemic of this sort, that would be catastrophic for our advanced economy. I beg the Minister to consider that matter briefly as well.
	What is the department doing to find other methods for making vaccines? At the moment, of course, vaccines are made using—slightly ironically—chicken's eggs. We make viruses, which are the centre of vaccines, by many other methods. In my own laboratory we use cell culture. We have been doing that for a number of years and at the moment I think I am stockpiling enough virus—not influenza—to poison the whole of west London. But that is not the point. It is actually quite an efficient way of using cell culture. Have the Government any plans to consider that and to consider, if cell culture were used—there are specific problems about using those viruses in humans—how we might address how that would be used and how we would address safety?
	Another question that concerns me considerably is the regulatory process which could delay new drugs being offered to patients. Again and again, we heard from every witness that a key aspect of dealing with such a pandemic is to nip it in the bud as soon as possible—even 48 hours after infection is probably too late. The need to act really urgently is a key issue when using new drugs and in relation to the research and clinical trials on the use of new drugs. There are certain problems. At the moment there is no chance of getting approval for a randomised clinical trial, which would be needed in such an event, through the average ethics committee. At the moment, on average it takes perhaps four to six months, which is not unreasonable in view of the pressure, but I believe that the Government will need to consider that, speed up ethical approval and look at the issue of informed consent.
	Does my noble friend consider that the Human Tissue Act, as it stands, could cause serious problems when collecting specimens, with or without consent, for us to look at promptly in the laboratories and assess the virus under different experimental conditions? The scientists believe that that is a crucial point but there are certainly likely to be problems with the current regulation. If there were a national emergency, would the Government suspend that Act of Parliament?
	I want to ask about a point on which we had a very vague answer. If new drugs were seen to be useful, might it be possible for the Government to consider indemnifying manufacturers? On the whole, manufacturers do not find making vaccines a particularly valuable thing to do commercially. There are problems with vaccines, one of which might be the need to use them and antivirals urgently, perhaps without the full controls that we would usually expect, with the risk that there may be problems with insurance.
	I do not intend to speak for my full 15 minutes. This is a very useful debate on a very important issue, but I have one other question on which I think my noble friend Lord Patel—although we do not sit on the same Benches—agrees with me. I believe we agree strongly on many issues. One of the concerns is that the Government, as he said, have prepared pretty well. There is no doubt that we should pay a major compliment to the Government, which have done much more than other advanced countries. For example, we have stockpiled much more vaccine, I understand, than some of our neighbouring countries. But there is a problem, and it was raised very much during the evidence we took.
	The issue is, suppose there was an outbreak in a neighbouring country in Europe, would we be prepared immediately to release the drugs that might be needed to nip that infection in the bud so it did not spread beyond its confines? That is an important question. Certainly, the need to understand the international connections with many of these infections, not just flu but a whole range of them, needs to be taken on board much more clearly in future because obviously we are facing, even though it may be small, a very serious threat indeed.

Baroness Masham of Ilton: My Lords, I thank my noble friend Lord Broers for inducing the report so clearly and expertly. I would also like to thank the Science and Technology Committee for this most important report. The debate has been most interesting and revealing. There is much to be concerned about in the report. As has been said it is timely, as the situation in Turkey worsens with an increase in the bird flu virus. Thousand of birds in Kusadasi, which means "bird island", were destroyed on Wednesday and Thursday last week after a dead pigeon, a duck and a blackbird were confirmed as having had the disease. This shows that no bird species is immune.
	I feel that this debate, which involves many government departments, should have had two Ministers speaking, who would be more likely than one Minister to cover aspects of health, veterinary science, agriculture, travel and transport, tourism, food and finance, as well as many other bodies.
	Since H5N1 arrived in Turkey, where several children have died, it is evident that this is a very dangerous virus. As Turkey is closer to the UK than previously infected countries, and with increasing cases, it seems more likely that the virus will arrive in Britain. If children can get ill after touching infected gloves, utmost care must be taken.
	I must declare an interest: I have chickens, peacocks and white doves, and I live where there are many birds of all sorts—pheasants, ducks, geese, grouse, pigeons and wild birds, big and small, of many varieties.
	It is very sad to see the extermination of birds in Turkey and what it means to people who love and depend on their poultry. A man said that he would rather get rid of his wives than his hens! Until this virus goes away, there will be yet another cloud hanging over many people, as it did in the disastrous period of foot and mouth disease. As the report says, prevention is better than cure. If a pandemic develops what will substitute for the shortage of eggs, which will be inevitable if hens have to be culled? In the war there were dried eggs and eggs kept in water glass. Should we be doing something now to stockpile? To make vaccines eggs are also needed, and that would surely be a priority use if they become scarce.
	In all the countries where H5N1 has been reported, government workers disposing of birds have worn masks and protective clothing. What risk assessments have been undertaken in preparation for a pandemic in the UK? What is the advice on masks? Have we plenty of all that is needed? Would people working closely with poultry be a priority for the limited Tamiflu antiviral tablets, as they would be most susceptible? Being prepared for a catastrophe, which we hope will never happen, is better than panic should a pandemic develop.
	I hope that the Minister will respond today to the recommendation on page 48 of the report. It states:
	"The Government should follow the example of the United States in making a major investment in developing new vaccine production techniques. The industry has been too conservative in relying on tried and tested methods; it is time for the Government to show leadership".
	The report goes on:
	"We welcome the initiative of the European Medicines Evaluation Agency in developing a 'mock-up' dossier for a pandemic vaccine. We recommend that the Government invest in one or more 'mock-up' dossiers with a view to removing the regulatory barriers to a new vaccine".
	I think that the noble Lord, Lord Winston, spoke about that. It continues:
	"We recommend that the Government fund further research on alternative treatments for pandemic influenza. This should include a full assessment of the risks and benefits of fractionation. If such risk analysis is left until a pandemic outbreak it will be too late."
	An article in the Times of Monday 16 January reports that Professor Hugh Pennington, president of the Society of Microbiology, said that the Government should vaccinate the whole country against bird flu. It states:
	"'The immediate threat is to poultry but we must be ready for it to spread by human-to-human contact,' the professor said. 'We can develop a vaccine on the current H5N1 strain found in birds within three weeks. That will give better protection than Tamiflu'".
	Is that the case? It sounds hopeful. I look forwards to the Minister's response.
	The report stresses the need for good communication to all sections of the population involved. I hope that the Minister will set an example today by answering this debate in a positive and thorough way.
	Noble Lords will most likely know that there has just been an international conference in Beijing on bird flu. The international community promised £1.1 billion to fight avian flu. "This is self-defence", said the EU Health Commissioner. The world's top public health authorities stressed that the critical next step would be to devise a strategy to allocate the money to desperate governments, particularly those in south-east Asia while ensuring the funds could be accounted for. The director-general of the World Health Organisation said that distributing the funds to countries would be "very complicated". A critical part is making sure that the money goes to the right place. Kofi Annan, the UN Secretary General, in a teleconference said:
	"There are widespread concerns that an unmanageable outbreak of virus mutation . . . in a single country may quickly spread beyond borders.
	"In many communities animal and health services area being taxed to the limit".
	Here in the UK, as the Minister will know, the headline of the Times yesterday was "Hospitals shut wards as cash crisis bites".
	Why are Government reforms causing so much concern throughout the country? As we are now facing a crisis in our much-needed NHS, what are the emergency plans for extra healthcare in our hospitals and the community, should a pandemic of avian flu break out? Has the Treasury put aside extra funds? What is the capacity for testing blood for the H5N1 virus in the UK? We seem to be doing it on behalf of many countries that do not have our expertise and facilities. What will happen in a pandemic? Are strategic plans in place for all these necessities? Are we prepared to cope in the event of resistant flu strains?
	We must have reassurances that we are prepared for the worst scenario. A high ranking Minister to co-ordinate this seems a wise recommendation.

Baroness Neuberger: My Lords, I add my congratulations to the Science and Technology Committee on their report, which is beautifully argued, concise and clear. It makes clear recommendations to the Government. I congratulate our Government—I know that the Minister will be delighted to hear this—on having got as far as we have in this country with contingency planning. I add my voice to that of others in saying that we appear to be better prepared than most, although that does not mean that we are well prepared enough. Some serious points have been made in this excellent debate, some of which I will touch on briefly, and some which I shall address more substantively.
	The number of available doses of Tamiflu was addressed by several noble Lords—particularly the noble Lords, Lord Broers and Lord Mitchell. How can the decision be made that 14 million doses of Tamiflu are enough? It could well be argued that they will be too many, and equally well argued that they could be too few. The thinking behind the decision, however, is not clear to us, and was clearly not obvious to the committee. It would good to hear the Minister address that point.
	Secondly, our level of preparedness for making vaccine was raised by the noble Baronesses, Lady Masham and Lady Sharp of Guildford, and the noble Lord, Lord Patel. Why did we not move faster, as the Americans seem to have done, to work on vaccines when we are world leaders in some kinds of vaccine production?
	Thirdly, I have a short but difficult question for the Minister: who will be the key protected workers? It always seem that, when we talk about key workers, we think of health workers, the fire service, perhaps the clergy—as the right reverend Prelate the Bishop of Southwell and Nottingham suggested—and perhaps members of the Government and, possibly, the Opposition. I can see the Minister shaking his head, but I have argued the point.
	However, we always forget that, in order to enable a lot of those people to get to work at all, there are those who provide childcare and care of the elderly. The decision as to who the key workers are, who get the first go at the vaccines and drugs—if the drugs are going to be used prophylactically—is an important question that the Government need to address.
	Lastly, I have a short but difficult point which many have made, including the Science and Technology Committee: what is going to happen with having a Minister at Cabinet level with responsibility for addressing the possibility of an avian flu pandemic, or other major contingencies? Can the Minister give us an answer today?
	I am representing the noble Baroness, Lady Finlay of Llandaff, in my speech, because both she and I were invited to, and supposed to be at, the Anglo-French Colloque chaired by the noble Lord, Lord Stevenson of Coddenham. We agreed that she would go and that I would stay and make at least that part of her speech that other noble Lords had not yet made. I will indicate the points that are hers and not mine, which seemed to be fairest way to deal with that.
	I have several points that I wish to make myself. The first is one on which I have the greatest personal experience—the readiness of the National Health Service, and, in particular, the PCTs, should a pandemic arise. The committee's report expresses considerable concern over the readiness of the NHS to deal with an outbreak of avian flu. Questions have been raised about the stockpiling of drugs and the capacity of the system to deal with a surge in primary care consultations. The Royal College of General Practitioners, and others giving evidence, argued that a contingency plan for 5,000 to 10,000 additional flu-like consultations a week—compared with a normal 30 consultations per 100,000 for flu and a pandemic standard of 250 per 100,000—begs enormous questions of our contingency planning. What will the Government do to ensure capacity? Is there sufficient capacity in the system at all, or will we want to bring it in from, say, Germany, where doctors have been striking because of pay and coming here to spend their weekends? Alternatively, will we want to stop international travel, which will render that impossible? Will be want to bring in retired doctors to increase capacity and, if so, what arrangements are being made to enable that? Is there sufficient energy and capacity in the PCT system to cope?
	My honourable friend in another place, Steve Webb, the Member for Northavon, did a survey of PCTs, published earlier this month, suggesting that some 20 per cent of them are affected so severely by the current NHS shake-up that their plans for a possible outbreak of avian flu lack urgency. That suggests that 80 per cent do not feel like that, but 20 per cent is too many. It is a serious point. My own experience of chairing an NHS trust, and at the King's Fund, suggests that it takes something like 18 months to two years for organisations to recover from reorganisation. If we are facing the possibility of a pandemic in the relatively near future, we cannot take the risk of reorganisational chaos.
	Is it therefore now time to stop driving the changes so hard—indeed, to call a halt to mergers? I knew that the Minister would shake his head. It seems that there is at least an argument for calling a halt to rapid change in the system. My first substantive question to the Minister is: can he reassure this House that clear guidance and sufficient support have been given to PCTs to enable them to cope? Secondly, can a halt to changes and mergers now be made?
	Thirdly—a point made by other noble Lords—will the Minister encourage close links between PCTs and local authorities? The whole point of PCTs being organised as they are at present is that they should share boundaries with local authorities. The evidence in this report, showing that local authorities have not necessarily taken all this seriously enough, suggests that urgent measures must be taken on board and that local government needs to be encouraged in that respect, as the noble Lord, Lord Jenkin of Roding, and the noble Baroness, Lady Byford, made clear. The Government need to take on board a specific question for local authorities: have the Government encouraged local authorities to take on board local questions, such as isolation of an outbreak should one occur?
	Fourthly, are there plans in place in PCTs? It did not seem that the committee heard sufficient evidence to satisfy it about the local availability not only of antiviral drugs, but of antibiotics, oxygen—which we rely on local pharmacists to supply—and other drugs and supplies that might be needed. Can that situation be reviewed now, rather than at the beginning of a possible pandemic, when it may well be too late? If the Minister is able to reassure us about that and tell us that the current planning blight that emerged in evidence to the committee and elsewhere will be lifted to allow proper preparations, I believe that the House will be very relieved.
	My second major area of concern, which the noble Baroness, Lady Finlay, shares, concerns rationing and how PCTs will encourage self-management. How will district nurses be encouraged to ration their services? How will triaging be worked? How will GPs know how to ration antiviral drugs? What about the other drugs, which the noble Lord, Lord Patel, mentioned? What about the rationing of vaccines, if we do not have enough for everybody? Who are key workers? What decisions have been made about whether drugs should be given prophylactically and to whom, or whether they should be given only in confirmed cases? At what level of diagnostic certainty does dispensing come into force when we have no quick, definitive diagnostic test for avian flu thus far? The noble Lord, Lord Patel, made that point. Will the Department of Health monitor outcomes to inform the prescribing algorithm? How will district nurses care for the sickest at home so that massive hospital admissions can be prevented and isolation maintained? Will we be able to recruit a sufficient number of retired district nurses to help? Indeed, can the Minister tell us whether any planning has been done by Government, the chief nurse or the Royal College of Nursing on this? We need to know.
	My third area of concern is about the flu surveillance unit of the Royal College of General Practitioners—and I must declare an interest as an honorary fellow. Other noble Lords have also made the case that the flu surveillance unit has an international reputation, but it does not know about its funding beyond April and has spent 18 months trying to get reassurance on it. Can the Minister give us reassurance on it?
	The Health Protection Agency and primary care trusts gave interesting evidence to the committee. Mrs Hutchinson's evidence was that it took some time—how can I put it better?—to sort out the relationship. There was also Pat Troop's evidence about the squeeze of resources on the HPA at the time of the review of arm's-length bodies and the ongoing budget squeeze. None of us wants to see a proliferation of arm's-length health bodies, but it makes sense in the present circumstances, with a pandemic possibly on the horizon, for the HPA not to feel blighted or squeezed, as the noble Lord, Lord Mitchell, said. Similarly, the Royal College of General Practitioners' flu surveillance unit needs to be reassured that it has a future and can carry on with its excellent work. It is surely a question of priorities until it is clear whether we face a pandemic.
	On my fourth area of concern, I shall quote the noble Baroness, Lady Finlay, on the issue of research:
	"If research projects are not in place and ready to start in the event of a pandemic, then potentially many lives will be lost unnecessarily. Protocols must be worked up in detail and be through the different regulatory hoops for data and sample collection, for comparing the efficacy of single versus multiple antiviral drug regimes, and for comparing the therapeutic management of complications and infections. If the projected figures are right, then at least 50,000 will be so ill they will die. After a few hundred cases it could become clear how the severely ill should be managed, if they are all systematically studied. One model would be to use a cluster randomisation design so that, for example, all cases in Nottingham received one form of treatment such as steroids early when their lungs were affected but another cohort, say in Swansea do not. We have no idea if steroids will confer a survival advantage by suppressing the immune inflammatory response to the virus or will impair survival by precisely that anti inflammatory effect allowing the viraemia to progress. Yet if the question is answered in the first 1,000 deaths, the subsequently 49,000 projected deaths may be reduced. But when infection hits it will be impossible to write a protocol, obtain funding, get ethics approval and get the data collection system in place. Our regulatory framework around research is tight in this country, yet good research saves lives".
	The noble Baroness is arguing that perhaps the Civil Contingencies Act could come into force, as the noble Lord, Lord Winston, suggested, and impose such data collection, but unless all this is thought through in advance, such organised research will not happen and lives will be lost. The noble Baroness argues that,
	"it seems wrong to wait and rely on draconian powers when responsible debate and public planning could air views and educate now".
	I wholly agree with the noble Baroness on this. Although I am passionately in favour of consent from the public and believe that the ethics approval system in this country is very well organised, I believe that the public will want this research. However, they will need to understand it and to give consent in advance. It would be good to hear from the Minister that this planning is taking place now and that we can expect public announcements about it shortly.
	My fifth point is also one raised by the noble Baroness, Lady Finlay. What will happen with the devolved administrations in the event of a pandemic and the Civil Contingencies Act coming into force? Will the Cabinet Office, the committee or whoever is going to have responsibility override or impose decisions taken by the devolved administrations and their Ministers? How is planning about different grass-roots protocols being co-ordinated for consistency? How much is being devolved to individual nations? Who is checking on compatibility between nations? Further to the relationship with devolved administrations, will the Minister tell us what is being done with other EU countries, given what we know about the different rates of planning, the joint planning exercise and the fact that avian flu may be reaching Europe via Turkey?
	A disturbing article in the Lancet yesterday suggested that there is no evidence that Tamiflu will be as effective as people have hitherto suggested. Its authors warn strongly against relying on drugs to stamp out a potential flu pandemic. They suggest that we may be guilty of a certain amount of complacency. I am neither a scientist nor a doctor, but I found the article—which I have just got from the Library—somewhat disturbing. Its authors suggest that we should be thinking hard about older, more conventional public health measures on hygiene and isolation. They said that barriers, distance and personal hygiene are important factors in preventing the spread of avian flu. They also said that the use of Tamiflu could potentially increase the spread of the flu virus—people might take it when they have the virus, go back to work because they feel badly owing to such a shortage of staff in place, and spread the virus around. In case people do not take that possibility seriously, I remind noble Lords that the Minister was very poorly—not, of course, with avian flu—at the end of last term, when we were debating the dental regulations. He pushed himself to come to work. We need to consider seriously the extent to which we want people to stay at home and not spread the condition.
	On that issue, the Department of Health has said that it is misleading to claim that Tamiflu and Relenza are ineffective against avian flu. However, in its press release, it stated that it was looking for a back-up strategy. It would be helpful if the Minister could tell us who is looking for a back-up strategy and what kind of strategy they are thinking about.
	I have a few final points. First, there is a question of alternative treatments. Chapter 7.17 of the report refers to,
	"the bank of immune immunoglobulin for future prophylaxis".
	Will it be possible for antibodies derived from the plasma of convalescent patients to be used, as the Academy of Medical Sciences was suggesting? Dr Wood of the National Institute for Biological Standards and Control suggested that that would be quicker than making vaccine. Will that be possible, or will it not be allowed because of precautions against the spread of new variant CJD? Will we now do the risk analysis to identify whether the benefits of a so-called fractionation using that plasma outweigh the risks? Will this risk analysis take place now, at the preparatory stage, so that reasonable assumptions can be made about the risk of transmission of variant CJD and about the benefit of reducing influenza morbidity and mortality?
	That all relates to the preparedness of government and researchers. The public need to know that government and researchers are on the ball. Will there be a Minister at Cabinet level to co-ordinate that? Will regulation of research be considered and questions about risk and benefits be tackled? Will something be done to settle the mood of some PCTs that are worried about what is happening? Can we work out whether we have the right amount of Tamiflu stockpiled? Can we think more about hygiene, protection and isolation? Lastly, above all, as the noble Lords, Lord Winston and Lord Giddens, asked, can we hear more about the Government's communication strategy, so that the population will trust the Government?

Lord McColl of Dulwich: My Lords, I add my thanks to the noble Lord, Lord Broers, for this excellent report and congratulate the whole committee on producing it so quickly.
	As many noble Lords have mentioned, the UK is one of the best prepared countries for pandemic influenza. That is in no small part due to the John Major government, who were responsible for producing in 1997 the country's first ever influenza contingency plan, which has been admired throughout the world and heralded as a model for other countries to follow. It was a little surprising and disappointing that it was not updated until 2005, especially in view of the clear warnings given in 2004 in another place by my honourable friend Andrew Lansley, stressing among other things that antiviral drugs should be stockpiled without delay.
	Despite some criticism voiced today about the Health Protection Agency, it has taken a leading role in this important work and has closely co-operated with academics in this country and the WHO. I was in Switzerland two weeks ago doing some important work on geriatric cross-country skiing, and I took the opportunity of talking to the WHO. They were full of praise for the work of the Health Protection Agency for what they regarded as some superb work on modelling to predict how a pan-epidemic might behave. I am very impressed by the agency's excellent guidance material. They have trained some of the officials in Turkey, so we have every confidence that the laboratory work in Turkey is reliable.
	There is, however, a fly—a rather large fly at that—in the ointment, because the budget of the Health Protection Agency was cut last year on the basis that it was not a front-line service. It clearly is a front-line service which has responsibility for co-ordinating the health service response in England and Wales. With the prospect of a pan-epidemic hanging over us, the idea that the budget should be cut is very unwise indeed. I therefore make a strong plea that the Government must reverse their policy and restore that funding and increase it for this essential work.
	It could be said that the Government are spoiling the ship for a ha'p'orth of tar, but it is much more serious than that. The 1919 epidemic was, after all, one of the most devastating that this country has ever suffered. The noble Lord, Lord Giddens, has doubts about whether more people died of the flu than were killed in the war, but what everyone at that time knew very well was that servicemen coming back from the war would knock on the door of their house and find the whole family dead inside from the flu. As has also been mentioned, it destroyed a very large number of young men.
	What can the international community do for these poorer countries? As several noble Lords have mentioned, the international pledging conference in Beijing has been very successful in securing over $1 billion towards the problem. Our Department of Health, which was present in Beijing, announced that it would pledge £20 million over the next three years to help prepare for a pandemic influenza outbreak. The £20 million of untied finance will come from the Department for International Development. The statement went on to say that the UK could offer a range of expertise and experience such as laboratory testing, training, preparedness and planning, but that is exactly what the Health Protection Agency has been doing. Will the Government now channel some of the £20 million to that agency?
	The WHO has warned that the world is closer to an epidemic than at any time since the 1960s, as has been mentioned. Even though this country is one of the best prepared, it would take less than three months for a pandemic to hit the UK after an initial outbreak anywhere in the world. Three highly pathogenic flu sub-types are circulating among birds yet H5N1 seems to pose the greatest threat. It has jumped from birds to humans on at least 149 occasions since 2003. It was mentioned that 79 people had died; the figure is now 80, as somebody died yesterday—that is a mortality rate of over 50 per cent. So far six countries are involved: Cambodia, China, Thailand, Vietnam, Indonesia, and, recently, Turkey. Although the problem is on a much smaller scale than with the animal sector, every human infection gives the virus the opportunity to mutate, and it could change into a form that causes a pandemic by transferring from human to human.
	In this avian influenza disaster about 150 million birds have already been culled or died, which is the equivalent of 10 billon to 15 billion US dollars. That has seriously affected small farmers in developing countries; they are the ones paying the price. Those farmers are understandably reluctant to report unusual deaths, just in case they lose their livelihood and their protein source.
	Most human cases of H5N1 have involved backyard farmers and their children. The commercial poultry farms are much less of a problem, as they have good security measures and best practice; the small farmers are the problem. It is difficult to get human infection from those birds. It tends to happen in people who do not know how to reduce the risks of exposure, as the noble Baroness, Lady Sharp of Guildford, has pointed out. They are the high-risk people; they have close contact with birds and their conduct is not the best. What needs to be done is straightforward, but we need government commitment of human, infrastructural and financial resources to help to rebuild these countries and implement the essential measures. Control at source must be the best policy.
	The World Health Organisation stated that there has not been such a virus as this in years; it is so tenacious. It keeps appearing and reappearing, causing many human infections due to the unprecedented spread in the animal sector. This has not happened before; it has spread outside south-east Asia and is at the doorstep now of Europe. It has gone further and has recently infected tigers in Thailand, which could be very serious indeed. The tigers are eating the carcases of infected birds.
	First one has to control the animal sector and make preparations to prepare for the pandemic. This needs to be done, as has been mentioned, through disease surveillance in animals and human health, early warning systems, early containment response and preparedness to mitigate mortality and morbidity and to reduce the economic and social impact. Previous pandemics have involved different strains and we cannot be sure what future pandemics will involve. I find that prophesy and medicine are quite separate subjects, as I am sure the Minister would agree. But I think that the Department of Health has very wisely gone out to tender for sleeping contracts to give a guarantee to the successful firms that they will be involved in the preparation of a vaccine, so that they can start preparing well ahead. The department is to be congratulated on that.
	The antivirals available to combat H5N1 include Oseltamivir—we use the proper names rather than trade names for obvious reasons. Of the two agents available, the Government are stockpiling Oseltamivir, but I gather that that will not be fully in place until September. As the noble Lord, Lord Broers, has stated, the Government need to clarify their strategy for using these antivirals. At present, it is not clear whether they are to be used in part to prevent flu or only to treat it. If they are used to prevent it, a larger stockpile must be ordered urgently.
	Presumably those who contract the disease will be treated right at the beginning, but so will their contacts, their families and the people where they work. Like the German and United States Governments, the UK Government also need to consider purchasing alternative antivirals, and no doubt the Government are considering that. The argument that the Government have used until now for not ordering the Zanamivir is that it needs to be inhaled, which would be more difficult for elderly and young children who have the flu.
	In summary, the UK is well ahead of the world in its detailed plans, but it does lag behind in stockpiling the antivirals and this is regrettable. The Health Protection Agency has done a very good job. For the Government to cut it on the basis that it is not a front-line service is rather bizarre. I hope that the Government will agree to restore this essential funding.

Lord Tyler: My Lords, I thank the noble Baroness, Lady Dean, and congratulate her on initiating this very important debate, particularly for those of us who have close connections with the great county of Cornwall. I recognise that the experience of the noble Lord, Lord Berkeley, fully justifies endorsement of his passport. I hope he will not have quite so much difficulty when he next visits us. If he needs endorsement from a resident next time he comes to Cornwall, I shall be only too pleased to offer it.
	Rail travel is a crucial issue, as both noble Lords who have already spoken have said. Travel by rail in the region is increasing by 5 to 10 per cent each year. I think that may escalate, particularly as we have the fastest growing population in the whole country and there is a direct read across from that into rail passenger demand.
	The Greater Western franchise award to the First Group, which has been referred to, recognises both the need for more effective integration of transport services and service improvements, but the original estimates of demand were obviously too low. There will be a temptation to manage excessive demand for train travel by deliberately pricing passengers off the rails, which surely should not be something that we should encourage, rather than finding the necessary investment to create additional capacity. In the debate on 16 January, to which reference has been made, the Minister, in reply to my noble friend Lord Bradshaw, did not seem to be able to give much reassurance on those points, which was disappointing.
	It is particularly important, as has already been implied, that the main line beyond Bristol and the main line from Reading through Taunton to Exeter and onwards to Plymouth and Penzance receives a fair share of future investment. I also endorse what the noble Baroness said about Crossrail. None of us is against Crossrail, but we are concerned about the dislocation of the whole investment programme and of existing services while that is going through. I recognise the truth of the statement by the South West Assembly, which has just been issued, which says that rail services to the south west,
	"could be stuck in a 40 year timewarp if the latest Government proposals are approved".
	Rail services to our area desperately need room to expand. In the immediate future, as the noble Baroness has said, during the six-year construction period, there could be a major dislocation of services beyond the immediate area of London. I hope that the Government recognise that problem and that in the enabling Bill they will give proper recognition to the effect on capacity outside the capital.
	There seems to be a bit of a metropolitan obsession about Crossrail. We recognise that it is going to be very important but, if the implications for other parts of the country are not followed through, there is a real danger. Again, a spokesman for the assembly said:
	"If we are to make a serious attempt to reduce congestion on our roads, and improve sustainability, the region's rail services are the place to start, not the place to start making cuts".
	Within the south-west—and I mean the far south-west, the real south-west—there are other problems. There are pinch points. I think that the most serious one is the one to which the noble Lord, Lord Berkeley, has just referred, which is the line beyond Starcross through to Teignmouth, which runs alongside the Channel. Everybody knows that it is the most wonderful place in the world to see the sea beside the rail track. Nevertheless, it is at the mercy of the weather and the waves. I believe that with climate change we will have more problems. We are told that there will be a rise in sea levels, and an increasing frequency in severe storms which can simply dislocate the whole of the main line beyond Exeter. In those circumstances, we can anticipate more cancelled services and even perhaps the track becoming structurally unstable, so we must look at other possibilities.
	I hope that the Government, with Network Rail, will commission a feasibility study into upgrading the line beyond Okehampton towards Plymouth. The restoration of that line must be a viable possibility. If so, that may be an answer to the problem to which the noble Lord, Lord Berkeley, referred.
	Cornwall has, as the noble Baroness said, the EU structural funds—assuming they continue under Objective 1—which should be used to improve the branch lines. I have a particular interest in the Par-Newquay branch line, but I recognise that the Truro-Falmouth branch line is important, not least of course because the campus for the combined universities in Cornwall is so near to it. We all know that students are good users of passenger services on the rail network, so they must be provided for.
	I have deliberately left roads to second place because I think that the railway issues are so important. There have been, over the years—again as the noble Lord, Lord Berkeley, said—some disastrous on/off decisions about investment in the main spine roads of the south-west, notably from the cuts in the early 1990s. I am especially delighted that the notorious black spot—the bottleneck on the A30, which I am sure that the noble Baroness knows very well, between Innis Downs to Indian Queens across the notorious Goss Moor—has at last been tackled. I was delighted to be involved in the public inquiry. As a former Member of Parliament for that precise area, I know how important this is, not just in economic terms or for Cornwall's tourism, but for the communities around that area which have suffered from blight from all the traffic—heavy lorries in many cases that have been forced to take other routes through sensitive areas. Goss Moor is a SSSI. It is extremely important that the new alignment for the dual carriageway takes traffic away from that area. It is the worst bottleneck between Glasgow and Land's End, and the sooner it goes, the better. Change is on its way, and I am delighted at that.
	I am also delighted that we are making progress elsewhere in the region. I will not speak with personal experience of the dilemma on the Somerset/Devon border with the A30, where clearly there is a limited capacity. I know that local authorities are having some difficulty in deciding how precisely to deal with that. However, my party colleagues in the county halls of the south-west are tackling some very difficult problems in an imaginative and realistic way. Putting the emphasis in the road programme on those spine roads to make them fit-for-purpose, rather than simply spreading the money everywhere, is probably the right solution. Sometimes of course that can be counterproductive.
	I believe that there are a small number of schemes to remove dangerous stretches on, for example, the A39 "Atlantic Highway" in north Devon and north Cornwall. That would be a real help to the holiday traffic. But the most important issue we have to address is how we can take pressure off the infrastructure. I notice, for example, that the Department for Transport has been particularly enthusiastic in recommending Cornwall's transport access plan for patients, the so-called TAP, which is taking people off the roads most successfully as well as reducing the time wasted by those travelling to our major hospitals. There is also an interesting transport network scheme operating out of the Royal Devon and Exeter Hospital. All of that must be to the benefit of the overall structure.
	I shall refer briefly to air travel, with which I have been involved a great deal. I should like to add two points to what has been said. First, business passengers are on the whole not coming to London; they want to go to an interlining airport around London to travel to Europe or beyond. It is therefore extremely important that we retain the landing slots at Gatwick. We used to have them at Heathrow, which was even better. It is particularly important for the far south-west. We do not have an option of surface transport which is in any way comparable to what can be provided by air.
	With the medium-term survival of Plymouth airport inevitably in doubt because of its limited landing opportunities, it is extremely important that the Government should today declare precisely what support will be given for the transfer from military to civilian use of Newquay. I hope the Minister will be in a position to do so. It is absolutely critical to the region. It would be extraordinary if the Ministry of Defence was allowed to wash its hands of its responsibility and ignore the responsibilities of the Department for Transport. It would make a complete sham of joined-up government.
	I do not have time to go further. I am delighted to have been able to contribute to this debate. I again congratulate the noble Baroness on introducing it.